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Interview with Professor Rabie E. Abdel-Halim

In this last interview that closes this series of Muslim Heritage Interviews, Professor Rabie El Said Abdel-Halim, eminent expert in urology, poet and well known historian of Islamic medicine, details his passions for medicine and its history. Beginning from the start of his career as doctor and historian, he shows how he was inspired by the sentence of George Sarton that if we do not understand the history of scientific knowledge we will not be able to add to it. Professor Abdel-Halim describes in detail the contributions of the physicians and medical authors of the Islamic civilisation to various fields of medicine, from urology, to anaesthesia, surgery, anatomy, and others. For him, one of the most inspiring lessons we learn from the history of medicine and the history of science is that these disciplines broaden our world viewpoint and outlook to life. A thoughtful study of the history of science is bound to strengthen a unique feeling of brotherhood, unity and universality of mankind.

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The interview with Professor Abdel-Halim was performed in May 2009 through written questions to which he kindly wrote his replies (the editors).

Let me first congratulate you on receiving the History of Medicine Prize in 2005 from the Kuwait Foundation for the Advancement of Science and welcome you as a key associate and member of the Foundation for Science, Technology and Civilisation. We are glad to benefit from your knowledge and experience to shed light on various aspects of Islamic medicine that you have been practicing for many years as a historian and as an eminent doctor.

Professor Abdel-Halim, how has your interest in the field of Medicine developed and in particular the field of Urology?

None of my family, or of the whole of the north-of-Egypt village where I was born, was a doctor. It is the love of being a doctor deep seated in me since the early school days. This has been nurtured by an excellent biology teacher whom I will never forget. Same as my father, who was also a school teacher, he cultivated in me the sense and admiration of the marvels of creation in our bodies and around us. I remember seeing a huge book on human nutrition on his desk. He noticed I was curious about it and lent it to me. I read it with great interest in a short time and prepared handwritten copies of many of its pages and tables.

The inclination to the study of medicine is an essential requirement of succeeding in this long, protracted and tedious type of study. It is very interesting that more than 1000 years ago, Muhadhdhab al-Din al-Baghdadi laid emphasis on the detection of this natural talent, readiness and inclination in candidates applying for medical study. He even detailed, in his book Al-Mukhtar fi 'l-tibb, how to detect this talent by looking for a long list of physical, moral, psychological and mental attributes indicating a healthy temperament, proportionate physique and pure manners. For that reason, Al-Baghdadi agreed with Plato and Aristotle in condemning the ancient tradition of restricting medical education only to sons of doctors.

The interest in a particular medical subspecialty builds up in a medical student during his or her undergraduate studies. However, for the proper choice of a medical career, one has to follow his personal inclination and to find out for sure whether he is surgically or medically minded; not allowing any other factors to influence his or her decision. The surgical inclination was very clear for me right from the beginning. The career started in general surgery under the mentorship of the late great surgeon of Egypt Professor Muhammad Metwally Kennawy. In England two very efficient urological surgeons, Mr Norman Gibbon and Mr J. K. R. Rawlinson managed to convert me from the general surgical to the special surgical career: urology. I am so grateful for all of them.

How has your interest in the History of Medicine come about and has there been a specific trigger during this time that has developed your interest to study the history of Islamic Medicine?

Unfortunately, in our days, where I got my MB, BCh (Ein Shams University, Cairo, Egypt, 1962) and the Postgraduate Diploma in Surgery (same university, 1965), history of medicine was never taught to us. It was not a part of the under or postgraduate curriculum then. So, surprisingly enough, in the land of Ibn al-Nafis and Ali Ibn Radwan, we, as doctors, never heard about the great contributions made by medical scholars in our part of the world 1000 years back.

In fact, the first time I heard about Al-Razi, Ibn Sina and Al-Zahrawi and other Islamic scholars was in Liverpool (UK) in the late sixties when I came over to finish my training in surgery. It interested me a lot to read about those Arabic names in Western references. I came to know, from what I read then, that the Islamic scholars were mere compilers of the Graeco-Roman sciences who added nothing new. I, even, noticed that, with few exceptions most of the textbooks, periodicals and honorary historical lectures, especially those authored after the 3rd decade of the last century, completely ignored this Islamic era in most of the historical studies and reviews.

I also noticed the immense interest in the History of Medicine shared, practically, by all British surgical and medical periodicals, particularly in what relates to scholars like John Hunter, Harvey, Veaslius and other Europeans. This contrasted, in my mind, with the lack of such interest in our part of the world.

All of this helped to stimulate my interest in this field and started me on an endless journey of avid study and research. One of the first references I obtained for that purpose was the Catalogue of Arabic Manuscripts on Medicine and Sciences in the Wellcome Historical Medical Library edited by Albert Zaki Iskandar and published by The Wellcome Historical Medical Library Series in 1967. It was, in fact, one of the important books that further promoted my interest in the history of medicine. To see, for the first time, pictures of medical manuscripts authored in Arabic more than 1000 years back was indeed so inspiring for me. The introduction chapter of the editor was very informative and fascinating and the statement of the late Dr F.N.L. Poynter, in the forward section, about "the growing appreciation in the West of the importance of Islamic contributions to the history of medicine" was an encouragement to persevere with my self-sponsored research project in that field.

After you obtained your higher qualification and finished your surgical training, you had a lot of responsibilities as a consultant urologist. Meanwhile, as a professor of urology you had a lot of academic and teaching commitments. Did your study of the history of medicine interfere with those professional duties?

On the contrary, my interest in historical studies helped me a lot with my clinical and academic commitments. The more I learnt about the history of medicine the more I enjoyed the day-to-day practice of my specialty. In any practiced field of science, including medicine, it is indeed highly beneficial and enjoyable to grasp the evolution of knowledge from ancient civilizations across Graeco-Roman then Islamic eras up to our modern days' practice. This unbroken continuity of scientific progress is a step forward towards further discovery and originality.

More than 1000 years ago, Abu Bakr Muhammad ibn Zakariyya Al-Razi stressed on the same point saying that the scholar who attains complete knowledge of the achievement of those who came before him will be the one who is able to add original contributions to it. This was re-echoed last century by George Sarton who stated that "we shall not be able to understand our science of today, if we do not succeed in penetrating its genesis and its evolution". Consequently, if we do not understand our science of today we will not be able to add to it.

However, the only thing to mention in this context is that I had to spend much more of my off-duty and leisure-time in order to, simultaneously, accomplish both the clinical and historical commitments. However, because both types of commitments are actually acts of worship and are sort of hobbies to me, this extra burden was not at all troublesome. On the contrary, it was, indeed enjoyable.

Apart from enriching your clinical and academic career, did the study of the history of medicine and the history of science influence you in other ways?

It did broaden my world viewpoint and outlook to life. A thoughtful study of the history of science is bound to strengthen a unique feeling of brotherhood, unity and universality of mankind: a prerequisite of peace and harmony among members of multinational groups and work teams. This fulfils an integral aspect of our faith: the global outlook and commitment to all mankind.

The line of evolution of the history of medicine is continuous and uninterrupted. It has gone through several phases accumulating contributions of different civilizations and numerous nations extending across several phases of evolution. Indeed the medicine of today is a joint global contribution of the whole world.

It is noticed, however, even up till now that such an attitude of the universality of science is rare among the scholars of the contemporary Western civilization. As stated by Philip Rehbock, "the situation for truly global treatments of the history of science has been especially barren. Ever since Europeans began to write it in the late 18th century, the history of science has meant the history of Western science. Like the courses for which they have been intended, textbooks in the history of science have largely followed this orientation".

I found that this is in marked contrast with the attitude of the scholars of the Islamic era who respected the universality of knowledge and paid tributes to all contributors regardless of their colour, tongue, religion or ethnic and national origin. Accordingly, in their works, Al-Nadim, Ibn Juljul, Sa'id ibn Ahmad ibn Sa'id Al Andalusi , Ali ibn Yusuf Al-Qifti, Ibn Abi Usaybi'a and many other Islamic scholars looked upon the history of the progress of medicine as a global contribution by all nations, a heritage of all mankind.

In his book 'Uyun al-anba' fi tabaqat al-atibba', Ibn Abi Usaybi'a reviewed the progress of medicine from its beginnings up to his life time following a thorough, accurate and unbiased system covering in a chronological order all civilizations in all parts of the world over all the phases of the development of medicine.

Can you explain the contributions that Muslim scholars made to the field of Urology, by pointing out first what was the situation before their contributions in this field?

The progress of knowledge in Urology, like in all other surgical and medical fields (and in all other branches of science), is a continuous process that started with the creation of Adam (peace be upon him). Gradual build up of knowledge and experience continued from prehistory to ancient civilizations (Indian, Far Eastern, Assyro-Babylonian and Ancient Egyptian), then through Graeco-Roman and Alexandrian civilization to the Islamic and finally Western civilizations.

Each of those evolution phases has its own features and, hence, contributions to the line of scientific progress. It is only very recently that the features of the Islamic era in the history of medicine came to be studied and investigated. There is still a lot to do in this field of study. However, several features of Islamic medicine (The history of medicine during the Islamic era) are now quite evident and well documented.

As stated by Douglas Guthrie (1958) in his book A History of Medicine, the progress in medical knowledge during the Islamic era was motivated and inspired by Divine Revelation. In documentation for that statement, Guthrie cited the translation of an authentic prophetic tradition saying: "O, servant of God, use medicine because God has not created a pain without a remedy for it." Islamic medicine was stimulated by the concepts of faith. Learning and practicing medicine is an act of worship. Wisdom is highly appreciated and always sought for.

Another feature which influenced the contributions of Islamic medicine is that it exalted the soul, the mind and the body at one and the same time while strongly opposing magic, sorcery and establishing the principle that prevention is better than cure.

The primary attention given by Islamic scholars to preventive medicine (Hifz Al-Sehhah) is a hallmark which was stimulated by the teaching of the Prophet (peace be upon him) in the fields of hygiene, diet, bodily health, spiritual health, personal and environmental cleanliness and avoidance of contagion.

The Islamic system of medicine was also characterized by being constructed in a logical scientific and regular manner, taking the consecutive steps of first translating all the works of the predecessors, followed by critical evaluation of those works, rejecting what is superfluous and accepting only what proves to be true. Then original contributions started and flourished.

One of the most important original contributions made by the medieval Muslim scholars to the progress of urology and other surgical and medical specialties was the 11th century Ibn Zuhr (Avenzoar)'s application, for the first time, of experimental methodology in evaluating new, or controversial surgical procedures. The role of tracheotomy in the resuscitation of life threatening suffocation due to upper airway obstruction remained controversial for several centuries. According to Adams, Spink and Lewis, Aretaeus in the 2nd century and Caelius Aurelinus in the 4th century did not approve the technique of tracheotomy. Therefore, although Paulus (7th century) quoting Antyllus (2nd century), described the technique of tracheotomy, the operation remained in disfavor. This state of affairs lasted until the Islamic era when Al-Razi (9th century) and later Ibn Sina (11th century) spoke favorably of the operation and refined the technique. Although Al-Razi spoke of tracheotomy as a drastic measure, he reported seeing patients with wounds in the throat through which breath came out, yet the wounds eventually healed and patients survived.

Al-Zahrawi (Albucasis, 10th century), in his book Al-Tasrif li-man 'ajaza 'an al-ta'lif reported from his own experience the successful management of a suicidal cut wound of the trachea and concluded that tracheotomy is not a dangerous procedure. However, controversy continued in the time of Ibn Zuhr who noticed that tracheotomy, therefore, was not being carried out in patients who badly needed it. In order to sort out that controversy and prove that tracheotomy is a safe operation, Ibn Zuhr decided to do the following decisive experiment reported by him in his book Al-Taysir and translated as follows:

"Earlier on in my training when I read those opinions (controversies), I cut on the lung pipe of a goat after incising the skin and the covering sheath underneath. Then I completely cut off the substance of the pipe, an area just less than the size of a tirmisah (lupine seed). Then, I kept washing the wound with water and honey until it healed and it [the animal] totally recovered and lived for a long time."

This unique experiment represents a further step in the development of the experimental school started by Al-Razi (Rhazes) of Baghdad in the 9th century, who is known to have given monkeys doses of mercury to test it as a drug for human use. Nevertheless, we think, Ibn Zuhr can be still given the title "The Father of Experimental Surgery".

Ibn Zuhr's application of an experimental animal model to a clinical problem was the forerunner of the method by which many current surgical procedures were developed. The authors who came after him in the 13th century such as Al-Baghdadi and Ibn El-Quff recommended tracheotomy unreservedly in life-threatening upper airway obstruction not relieved by other means, and described the technique with more refinements and in more detail.

It will take long to detail other documented contributions made by the medieval Islamic medical scholars. They added original contributions to the progress of urology and pioneered new fields of medical knowledge and practice such as medical ethics, medical education, medical certification, health education, preventive medicine, hospitals and hospital training, medical-practice quality control, clinical medicine, differential diagnosis, experimental medicine, experimental surgery, beginnings of specialization, pharmacology, use of anesthetics, and many other new discoveries in anatomy, physiology, pathology, therapeutics, surgical instruments, and surgical techniques.

You have written numerous articles on the topics of urology and pathology. Can you mention some of the instruments that Muslim scholars may have played a role in devising to treat patients in these fields?

The more we look into the Islamic scientific heritage, the more we discover original contribution, ingenious devices and inventions developed by Islamic scholars in various fields of practice. In the field of urology, we have documented the invention of new types of urethral catheters, bladder irrigation syringes, instruments to crush stones in the urethra and in the bladder (lthotrites) by the 10th-century Abu Al-Qasim Khalaf Ibn Abbas Al-Zahrawi (Albucassis) (325-404 H, 930-1013 CE).

The procedure of crushing a urethral stone by Al-Mishaab lithotrite was not described by any of the ancient or Graeco-Roman scholars. It is therefore an original contribution by Al-Zahrawi. It laid the foundation for the principle of lithotripsy, an important landmark in the evolution of urology. Al-Zahrawi's procedure became widely recognized in Europe until the 19th century, which witnessed a period of ingenuity on the part of surgeons and surgical instrument makers. Therefore, by the notion of getting at the stone while actually within the bladder, Al-Zahrawi's idea of drilling by Al-Mishaab (which was introduced in the bladder along a metal canula) was the foundation of the litholepte of Fournier de Lempdes (1812), the instrument of Gruithusien (1813), Civiale's trilabe (1818) and the brise coque of Rigal De Galliac (1829).

Al-Zahrawi also invented a new scalpel for the operation of cutting on bladder stones (cystolithotomy) with two sharp cutting edges and, being a novel instrument not known before him; he made a drawing for it in his famous book Al-Tasrif. This innovation invented by Al-Zahrawi is different from the lithotomy scalpel which was in use during the Graeco-Roman era from the days of Meges of Sidon in the 1st century. The scalpel called "Novacu1a" used by the Italian surgeon Marianus Sanctus in the 16th century, and the scalpel used by the English surgeon Shelsden in the 18th century, were very close in shape to Al-Zahrawi's scalpel.

Furthermore, in the technique of cutting on the bladder stone, Al-Zahrawi was the first to use a forceps to extract the stone. Before him, extraction of the stone was by an instrument similar to a small spoon that goes around the stone and scoops it out. Al-Razi (Rhazes) used that spoon-like instrument and called it "Al-majarrah" (the dragger, the scoop). However, he also described that, for dragging a stone out, need may arise to use the "Al-Kalbatayn" which is similar to the Arrows Extractor forceps. But Al-Zahrawi introduced, for that purpose, a new instrument with a better grasp on the stone. The use of Al-Zahrawi's stone forceps spread to Europe during the Middle Ages and Renaissance. The drawing of the stone forceps shown in Marianus Sanctus book (the middle of the 16th century) is exactly the same as the description and drawing of Al-Zahrawi forceps.

It was Al-Razi (Rhazes) (841-926 CE) who first doubted the belief, prevalent among the ancients that breaking of the stone inside the bladder during or before its removal endangers the patient's life. In his book Al-Hawi (the Continens), after citing that Antylus the Greek (2nd century) adhered to that belief, Al-Razi commented: "This is to be looked into, God willing." However, Al-Razi, realizing before Al-Zahrawi, the dangers of resorting to a large incision to extract a very large bladder stone, described a technique in which the sides of the stone were made to protrude out through the small perineal incision, then they were pinched off, one after the other, with the Kalbatayn forceps which is similar to the Arrows-Extractor forceps; that repeated breaking away of the stone sides outside the bladder was continued until the stone became small enough to come out without the need to fragment it inside the bladder.

That technique of Al-Razi was an important advance in the evolution of bladder stone surgery which was soon followed by the breakthrough innovation of Al-Zahrawi describing a technique and an instrument to crush a large stone inside the bladder, thus enabling its piecemeal removal. That innovation by Al-Zahrawi was an important landmark in the development and evolution of bladder stone surgery as it helped to decrease the mortality and morbidity of the operation. He vividly warned that it may result in death or permanent incontinence if a very large incision was resorted for extracting a very large intact stone. He condemned that procedure and considered it utter ignorance. Both Spink, Lewis and Kirkup considered Al-Zahrawi's innovation of crushing a stone inside the bladder, to enable its piecemeal extraction, as the foundation of the modern lithotripsy principle. They described his instrument "Al-Kalalib" as a primitive lithotrite.

The use of Al-Zahrawi lithotrite Al-Kalalib spread to Europe during the Middle Ages and Renaissance; its impact on European surgery remained until the 18th century. The lithotrite introduced by Andreas da Cruce in the early 18th century was, in fact, a modification of Al-Zahrawi's lithotrite in which the manual compression on the handle was replaced by a screw action.

Al-mirwed is the name of the surgical instrument described by Al-Zahrawi for various uses in several chapters of his book Al-Tasrif. Consistent with those descriptions, Al-Mirwed is a metal probe or a sound of so many uses. Before Al-Zahrawi, there is no previous similar mention of using it as a tool to confirm the presence of the stone before proceeding with the operation of cutting unto it. Therefore, in agreement with Spink and Lewis, this is another original contribution of Al-Zahrawi in this field.

Al-Zahrawi is, also, the first surgeon reported to introduce, in complicated cases, the two-stage bladder stone operation. His teaching, based on his own experience, spread East and West and influenced European surgery for several centuries. Covillard, who recommended the two-stage operation in the 17th century, was in actual fact repeating the same advice of Al-Zahrawi.

Furthermore, in chapter 61 of volume 30 of Al-Tasrif, Al-Zahrawi described in details the technique of extracting bladder stone in women. In the works of the ancient and Graeco-Roman scholars, there is no mention of the technique of cutting on the stone in women. It is not reported in the book of Paulus Aegineta which includes a comprehensive summary of surgery from the ancient era until the author's time (6th century CE). Similarly, Al-Razi did not discuss this topic. Therefore, this chapter by Al-Zahrawi is considered an important original contribution to the progress of urology.

With regard to the Islamic contributions to the progress of pathology, we have documented that Ibn Zuhr resorted to performing post mortems on sheep in the course of his clinical and therapeutic research on ulcerating diseases of the lung in human beings. Furthermore, Ibn Zuhr's description of the pericardial effusion in patients with serous pericarditis as "looking like urine" matches well with the current description of this fluid as "straw colored". This, also, indicates that he had seen and observed a collection of a fluid that could have never been obtained except by either pericardiocentesis (aspiration) or post-mortem examination. On the other hand, Ibn Zuhr's description of "solid substances accumulating on the inside of the heart's covering looking like layers upon layers of membranes" could not have been made possible without carrying out a post-mortem dissection. This is in line with the emphasis laid by his predecessors in the Islamic era on the importance of a thorough knowledge of anatomy and pathology for both physicians and surgeons.

It is also very interesting to find, in one of the engineering manuscripts authored during the Medieval Islamic era, a sophisticated drawing of a measuring instrument used to measure the amount of blood removed from a patient during a blood letting session (Fasd), a mode of treatment which was carefully used in certain cases during that era. This drawing when fully investigated and documented will represent an early start of bio-medical engineering by the medieval Islamic scholars.

In the conventional educational system in the West, there has been a norm of describing a historical period as the "Dark Ages" where the perception is that scientific advancements in the West were at their lowest ebb. However, there is a general lack of acknowledgement of the amazing contributions that Muslim scholars made during the period termed as the "Dark Ages." Have you found this to be true also in the research you have carried out in the field of the historical evolution of medicine?

Indeed, I found it to be true. It is noticeable that, in any contemporary article on medicine, the more than 1000 years between Graeco-Roman times and the modern era are commonly over-looked; giving the appearance that during this period nothing worthy of mention happened in medicine. And the same holds true with respect to mass media resources and curricula at schools and colleges.

In Europe, this period is usually referred to as the Dark Ages, in which the great era of the Graeco-Roman medicine came to an end and no progress in medical science was made until the Renaissance. The state of decline of medicine in Europe during that period is well documented in detail by all Western historians. As stated by Cumston, "at the time when the Arabs appeared in the Orient, Greek science was in complete decadence and the practice of magic reigned supreme". In another place, Cumston reiterated that "while the Arabs were raising civilization to the highest degree, the Greek nation slowly but surely continued to the most complete decadence… Forgetting the rational principles of Hippocrates and Galen, the Greek physician sank into empiricism, mysticism and the strangest superstition."

However, in the East, according to Dickinson, Sarton, Cumston and Margota, the firm establishment of the Muslim supremacy coincided with the development of botany, pharmacy and chemistry, branches of science that the Muslim world is given credit for having established. With the spread of Islamic civilization between the 9th and the 16th centuries, the study of medicine and other branches of science revived and acquired a scientific basis.

Nevertheless, with few exceptions, most of the current studies on the history of medicine still ignore the scientific and technological events of the period. Furthermore, with few exceptions, almost all history-of-medicine research centers worldwide focus only on local history and pay little attention, if any, to further studies in the medicine of the Islamic Era.

The examples for this literature gap in the history of medicine during the Islamic era are too many to list. It is quite a common finding in the current references and textbooks. In the West, it has inevitably been the tradition to highlight Eurocentric culture based on endorsing and attributing all, exclusively and solely to the Roman and Greek cultures. This is the case not only with the historiography of medicine and other applied sciences, but also with that of literature, sociology, general history, philosophy and all other venues of human thinking.

This has broken an important link in the globally continuous line of progress and evolution of world civilizations.

In your opinion, what are the causes and factors that propagate this literature gap or "missing link in the history of medicine" as you call it?

There are several factors that aggravate and propagate this serious gap in the history of medicine. In all of those factors, the blame falls primarily on the universities and research institutes of the Arab and Islamic countries.

First of all, very little or no studies are based on primary sources. Most of current resources are copied from previously published secondary source articles, without checking the edited and published original manuscripts. Such articles easily propagate omissions, deficiencies, misunderstandings, distortions and unfounded claims.

Moreover, with few exceptions, there is no interest in the history of medicine studies and research in the universities of the Arabic and Islamic World. Furthermore, contrary to the whole of the Western World, the history of medicine is not yet included in the under graduate or post graduate curricula of the medical colleges of the Arabic and Islamic countries.

Similarly, although many original authentic medical manuscripts written by famous scholars of the Islamic era were authoritatively edited and published during the 20th century, the number of primary-source studies based on them by historians or medical researchers remains very little; possibly because of the lack of academic departments or research centers devoted to the history of medicine in those countries. Furthermore, hundreds of medical manuscripts are waiting for editing and publishing. This represents a great obstacle as no one else care for this neglected world treasure of knowledge.

Therefore, since the early seventies of the last century, we focused on this missing-link era and performed several primary-source studies utilizing the already published original medical works of Al-Razi, Ibn Al-Jazzar, Al-Zahrawi, Ibn Sina, Ibn Zuhr, Ibn Rushd, Muhadhdhab al-Din Al Baghdadi, Ibn al-Baytar, Ibn al-Quff and Ibn al-Nafis, who lived and practiced between the 9th and the 13th centuries.

Our study critically evaluated the contributions of this list of Islamic scholars to the progress of clinical medicine, anatomy, physiology, preventive medicine, medicine, surgery, urology, anaesthesiology, antenatal care, paediatrics, social paediatrics, pharmacy, health education, medical services, hospitals, hospital training, medical education and medical ethics. Their original works were compared with those of their predecessors and those who came after them. Their influence on medieval Europe and European Renaissance was traced, evaluated and documented. Furthermore, original translations into English were made of relevant excerpts of all the works studied.

Back again to the Medieval literature gap in the history of medicine. While implementing your research project, what were the manifestations of that missing link you came across?

Firstly, while Charles Homer Haskins, George Sarton and very few other science historians emphasize "continuity and change" as the hallmark of the Middle Ages, one typically observes "discontinuity" and an almost exclusive "universalization" of the European Dark Ages in literary history pertaining to almost all branches of knowledge. Much of the literature reflects painstaking efforts to completely omit, negate or minimize the significance of Islamic linkages; the Greek heritage is the primary emphasis.

Secondly, the role played by the scholars of the Islamic era is only acknowledged as mere transmitters of the Greek heritage to Middle-Ages Europe, denying them any other achievements, additions or original contributions. Although few Western historians in the first half of the 20th century like Briffault, Ronan and Sarton did not approve such posturing, the current literature in the history of medicine and the history of science is still replete with such mistaken and erroneous claims minimizing the role of the whole Islamic era to mere preservation of Greek science.

Another manifestation of the missing link is the toleration of the names of only few medieval Islamic scholars as if they were exceptional individuals who sporadically existed and as if there were no others like them in the whole Islamic era. This ignores the fact that a fully developed Islamic civilization, involving all aspects of life existed in that era, and led to the flourishing of an original school of medicine which regulated medical education, medical ethics and certification, established hospitals as genuine medical facilities and provided health services at primary care level both in urban, rural and military settings. There are documented biographies already available for hundreds of famous medical pioneers and professors indicating that thousands of practitioners existed during that era.

Even with the few names like Rhazes (Al-Razi) and Avicenna (Ibn Sina), commonly quoted in the Western references because their original works are not checked or studied, nothing much is mentioned about their original contributions and they are usually acknowledged, only as mere compilers of Greek medicine.

Another form of exclusion of the Islamic era from the history of the progress of medicine is plagiarism, which consists in publishing the Latinized works of the Islamic scholars under the names of medieval European authors. The famous example for this practice is Constantinus Africanus who, as stated by Cambell, suppressed the names of the Arabic authors whose works he produced Latin versions of in the 11th century. Even more worse is the attribution of the commentaries of the Muslim scholars on the works of Galen to Galen himself. The same happened with the Muslims' commentaries and additions to the important work of the 1st century eminent herbalist Dioscorides. That is why Cumston noted that many of the medicinal remedies reported by Dioscorides are of Islamic origin. The same may be said of the work of Celsus (1st century) which was hardly noticed by the Greeks and overlooked in the Middle Ages. In the section on emollients (vol. 2), Celsus describes one of them as the invention of a certain Arab, and some of his recipes are based on Arabic materia medica with its tables of weights and measures (pound, dirham and dinarium or dinarii).

The missing link phenomenon is also well represented by the many distortions and misunderstandings copied from one secondary source to another. The examples for these distortions, misunderstandings and even accusations are too many to list. They are abundant both in reference books, scientific articles, newspapers, information media and Internet. Most typical is the following erroneous quotation currently found on several online encyclopedias: "Independent investigation in the fields of exact science, anatomy, and physiology was forbidden by the laws of the Quran"!

Could you give us an example or two of the above mentioned missing link manifestations.

As a first example, the missing link in the history of clinical medicine: Kenneth Walker, professor of medicine at Emroy University in Atlanta, in a chapter on "The origins of the history and physical examination" in his book Clinical methods and laboratory examination published in 1990, named "ten individuals as responsible for the development of modern physical diagnosis: Hippocrates then Vesalius, followed by 8 others. He stated that their accomplishments form a ‘golden thread [that runs] throughout the history of the world, consecutive and continuous, the work of the best men in successive ages."

There is more than a 1000 years gap in this golden chain between Hippocrates and the 16th century Vesalius. This gives the impression that no progress in clinical medicine occurred during the Islamic civilization era; the period between the Graeco-Roman civilization and the European Renaissance.

Contrary to Kenneth Walker, our study documented many important original contributions to the development of modern clinical methods by the Islamic scholars during that same period. We have shown the supreme abilities of the 9th-century Abu Bakr Muhammad ibn Zakariya Al-Razi as a clinician. Sections from his encyclopaedic book Al-Hawi were translated to show how he presented various pathological conditions, usually starting with the complaint, then analysing its origin and finally describing the signs necessary for diagnosis. In addition to careful history taking, complete general and abdominal examination was performed in order to reach an accurate diagnosis. He was a keen observer, differentiating with great precision among various conditions that produce similar complaints and accurately describing physical signs necessary for diagnosis. Therefore, he was a pioneer in clinical methods. As described by Garrison and Morton, he ranked with Hippocrates and Galen as one of the founders of clinical medicine. He is the father of the art of differential diagnosis, being the first ever author to write a separate book on that topic essential for diagnosing diseases that produce similar symptoms. This book Ma 'l-fariq (sometimes quoted as Ma 'l-furuq) (What is the Differentiation), also entitled as Kalamun fi 'l-furuq bayn al-amradh (A Discourse on Differentiating Diseases), is a landmark in the development of modern clinical methods.

His famous monograph on smallpox and measles Kitab al-judari wa-'l-hasba is the first description of and guide to the differential diagnosis of variola and is "the masterpiece of Muslim medicine" as described by Sarton, Withington and Campbell. In this book, Al-Razi first notes that recovery from small-pox prevents subsequent reacquisition, propounding the first theory of acquired immunity and leading in the 18th century to vaccination.

Furthermore Al-Razi described the use of trans-illumination in the diagnosis of fluid containing swellings. He also described, for the first time, a clinical physical sign on rectal examination, to diagnose, preoperatively, the presence of more than one bladder stone.

Accordingly, we have disproved the erroneous belief held by many contemporary medical historians that in the medieval ages, physicians never examined or came in contact with their patients but made their diagnoses from looking only at their flasks of urine, as recently published by Fischer in the American Journal of Surgery. We have shown that this was not the case in the East where, coinciding with the spread of Islam, the study of medicine and other branches of science revived and acquired a scientific basis during the same period. Under this influence, Al-Razi opposed every form of charlatanism and combated the exaggerated importance that was given to the examination of urine. His appraisal and classification of the findings on urine examination was based on an emerging scientific method relying on accurate observation and careful clinico-pathological correlation.

Scholars who came after Al-Razi, like Ibn Sina and Al-Zahrawi, continued to follow his pioneering school in giving prime importance to clinical observations and differential diagnosis.

The reliance of Ibn Zuhr on his own clinical observations, together with his skill in differential diagnosis and his interest in clinico-patholgical correlations, shines through in all sections of the book Al Taysir fi al-mudawat wa-'l-tadbir.

Same as all his predecessors in the Islamic era, Muhadhdhab al-Din Al Baghdadi, in his book Al-Mukhtar fi al-tTibb, stressed the importance of clinical medicine and gave more details related to history taking and examination. This is in agreement with Cumston who described the Arabian physicians as keen observers who excelled in diagnosis and prognosis with their description of symptoms showing a precision and an originality that could be only obtained by direct study of the disease.

These findings not only fill the wide gap in Kenneth Walker's statement about the landmarks in the progress of clinical methods, but also prove the originality of the scholars of the Islamic era, refuting the accusations that they were mere transmitters of Greek medicine who added nothing to the progress of medicine.

The second example is the missing link in the history of anatomy and physiology. Garrison, like many contemporary medical historians stated that: "The anatomy written and compiled, in the second century, by the eminent Roman physician Galen remained unquestioned until the 16th century; the time of the great anatomist Andreas Vesalius".

This statement of Garrison, repeated by Glimscher and by French, Martin and many other historians, together with the accusations that Quranic teachings prohibited dissection, gives the impression that no progress was made in human anatomy and consequently in surgery during the Islamic era, the period between Galen and Vesalius. However, this is disproved by the published results of our ongoing study of the original works of the medieval Muslim Scholars.

We have shown that Al-Razi, Ibn Sina, Muhadhdhab al-Din al-Baghdadi (12th century), Ibn Zuhr and Ibn Rushd (12th century) emphasized on the value of dissection and the knowledge of anatomy in diagnosing diseases, relationships of affected organs to one another, and applying adequate medical treatment.

Also a similar view was held by the 13th century Islamic physician Ibn Al-Nafis (13th century), the discoverer of the pulmonary circulation, in his book Sharh Tashrih Al-Qanun. Furthermore, in this book, he wrote a special chapter on the best mode for dissecting bones, peripheral vessels and internal organs. Meanwhile, both of Ibn al-Nafis, in his just mentioned book and Al-Razi in his book Al-Mansouri, frequently mentioned the word "Al-Musharrihon" which in Arabic means the dissectors.

Ibn Rushd (Averroes) stated that: "Anyone who practices anatomy will increase his faith in Allah". From the religious point of view, this statement by Ibn Rushd is of particular significance because he was, at the same time, the Grand Qadi (Chief Magistrate) of Cordova and a well known authority on Islamic jurisprudence in the whole Muslim world; then and up till now. Accordingly, his statement confirms that, contrary to Long, Levey, Martin and many others, the practice of dissection for medical teaching was not prohibited in the religion of Islam.

Furthermore, the presence of anatomical drawings within the text in Kitab al-mukhtar fi 'l-tibb of Muhadhdhab al-Din al-Baghdadi is a further step forward in illustrating medical text books; a trend that started and flourished in the Islamic era reflecting the role of direct observations and experience. During the whole of the Islamic era, with the increase in practical experience, the illustration of anatomical findings continued to progress in quality and in fine details. The drawing of the cross section of the brain and the eyes made by the 13th century Khalifa ibn Abi al-Mahasin al-Halabi (from Aleppo) in his book Al-Kafi fi al-kuhl (The Book of Sufficient Knowledge in Ophthalmology) is described by Hirschberg et al. as a time-honored diagram in which Khalifa al-Halabi managed to represent in a modest way what W. D. Sommering lucidly portrayed in his classic 19th-century illustration, more than 550 years later.

Moreover, Ibn Zuhr, in his book Al-Taysir fi al-mudawat wa-al-tadbir, emphasized that it is only the practitioner who practiced dissection himself and mastered the science who is entitled to do an operative intervention. The importance of anatomy for surgical training was a salient feature of medical education during the Islamic era.

From the days of Al-Razi and onward, the medical scholars of the Islamic era were keen on direct observation and experimentation. Ibn al-Nafis in his book Sharh tashrih al-qanun emphasized that "as regards the function of organs, we rely only on what is dictated by investigative observations and accurate research; not caring whether it conformed with, or differed from, the opinions of those who came before us."

Therefore, more than 600 years before the time of Vesalius, the interest and experience of the Muslim scholars in the study of anatomy led them to contribute to the advance of this important medical science by correcting many of Galen's erroneous anatomical concepts.

As an example, we have documented in detail how the ideas and findings of six Islamic physicians during the period between the Graeco-Roman era and European Renaissance, with reference to the functional anatomy of the urinary bladder, the anti-reflux and the micturition mechanisms, differed and contradicted with those of Galen but conformed well with our present day concepts. This is in agreement with the statement of Cumston that one is tempted to believe that the great Arab thinkers of this period foresaw many truths that modern discoveries have revealed.

We have also documented that Ibn al-Nafis, like his predecessors in the Islamic era, critically appraised the views of those who came before him in the light of his own experimentation and direct observations. Accordingly, in his book Sharh tashrih al-qanun, we find the first correct description of the pulmonary circulation. He also laid the seeds of the proper understanding of the systemic greater blood circulation. This is, also, evident from the statements in his other books Risalat al-A'dha' and Al-Risalah Al-Kamiliyah. Ibn al-Nafis was also the first to describe the coronary vessels and the true concept of the blood supply of the heart. Those discoveries of Ibn al-Nafis were translated from Arabic to Latin by the Padua-University professor Andreas Alpagus; the translation was printed in Venice in 1547. Six years later, Ibn al-Nafis' description of the pulmonary circulation appeared in the Christianismi Restituto of Servetus and, in 1555, in the second edition of the De Fabrica Humani Corporis of Vesalius. Similar descriptions were also given by Valvarde in 1554, Columbus in 1559, Cesalpino in 1571 then, finally in 1628 by Harvey.

Thus our findings also disproved the following statements of Charles Singer that "Galen determined a physiological standpoint which was not improved upon for 1450 years, that is until Harvey published his results in 1628". Furthermore, Browne's description of the anatomy of the scholars of the Islamic era as "second hand" and their physiology and pathology as "obsolete", were also disproved.

Furthermore, it is to be mentioned, in this context, that Andreas Vesalius Bruxellenis, the prominent figure in the development of anatomy and medicine in Europe in the 16th century, was quite familiar with Arabian medicine, not only through the Latinised works of the scholars of the Islamic era, but also by a direct study of their original Arabic works. According to Western biographic sources, while in Louvain in the year 1536, Vesalius published a more accurate translation from Arabic to Latin of the ninth book of Kitab al-mansuri of Al-Razi, the famous "Nonus Almansoris".

One year later, Vesalius was appointed as a professor of surgery and anatomy at Padua University, and 6 years later he published his marvelous famous book the De Humani Corporis Fabrica.

The fact that Vesalius translated the ninth book of Al-mansuri again from Arabic to Latin in the second half of the 16th century shows the continuing influence and popularity of that book at this time. This is in agreement with Sarton, Campbell and Withington who described that book as the most popular medical compendium of later middle ages in Europe. It also confirms that Vesalius, like other medieval European scholars, had a good command of Arabic language, the universal language of science then.

Other than Vesalius, who else among the famous medieval European medical scholars had a good command of Arabic language, the universal language of science then?

It is documented that the following well-known medieval European medical scholars and university professors had a good command of Arabic language:

1. Arnold De Villanova (1225-1311), the author of the Regimen Sanitatis Salernitanum.
2. Mondino de Luzzi (1275 - 1326), the well known Italian surgeon and professor at Bologna University who translated from Arabic Galen's famous book On The Use of the Parts.
3. Guy De Chauliac (1298-1368), the author of the famous work Chirurgia Magnum in which he quoted Al-Razi, Ibn Sina, Ali Ibn Abbas and Al-Zahrawi, 161, 661, 149 and 173 times consecutively. Guy De Chauliac translated from Arabic the 30th volume of Al-Tasrif book of Al-Zahrawi on operative surgery.
4. Andreas Alpagus (1450-1522) translated from Arabic Kitab Sharh Qanun Ibn Sina authored by Ibn al-Nafis, in addition to a new translation of Kitab al-Qanun itself.
5. Michael Servitus (1511-1553), the author of the famous book Christianismi Restituto.

Further research in the history of science in medieval and Renaissance Europe will reveal more and more of the wide spread of Arabic language among the scientists and men of letters in various parts of Europe during that era. George Saliba has recently cited the proposal of Zacharias Rosenbach (c. 1614) to introduce an Arabic language course for medical students at Herborn academy, the first and most important of the German academies founded in 1584, to enable them to read the Canon of Ibn Sina in the original. The fact that there were so many Arabic copies of that book sold in Europe (some 940 according to the records of the Medici Press) must mean that there were several European physicians, then, who could read Arabic to benefit from it.

The Foundation for Science & Technology has been working since its inception to dispel the amnesia in the mindsets of a lot of people about the amazing contributions that Muslim scholars have made to a diverse range of fields over the years and even today. Do you feel that in the fields of medicine today, enough is being done at universities, medical institutions, departments, both in the West and in the Muslim world by individuals, academics and practitioners, to appropriately acknowledge the contributions that Muslim scholars have made to the field of medicine?

The Foundation of Science and Technology is doing a badly-needed fantastic job to restore the missing link in the history of various sciences, including medicine as well as re-establishing the global continuity of world cultures and civilizations. As a researcher in the history of medicine during the medieval Islamic era, I feel indebted to the FSTC for the authentic thoroughly documented and accurate data I found in their publications; both online in www.MuslimHeritage.com and in the book 1001 Inventions: Muslim Heritage in our World".

However, the task is extensive and much further efforts are needed to fill this wide literature gap and to restore the missing continuity in the line of evolution of medical sciences. Individual efforts, though of help, are not enough.

All universities, research centers, heritage-revival centers, museums and historical libraries in all the Arab and Islamic countries have to shoulder their responsibilities in fulfilling the following badly-needed essential measures:

1. Establishing Departments for the History of Medicine in every university.
2. Encouraging academic staff to do primary-source research in history of medicine; each in his own specialty. This can be made as one of the promotion requirements, perhaps one paper for each promotion cycle.
3. Including the history of medicine courses in undergraduate and post graduate curricula of the colleges of medicine, pharmacy and science.
4. Encouraging editing manuscripts in Masters and PhD degrees as well as Post Doctoral studies.
5. Encouraging publications in the history of medicine aimed for both the higher and the general education levels and for public information media.
6. Propagation of interest in the history of science during the medieval Islamic era to other universities and research centers by interchanging resources as well as organizing international scientific meetings.
7. Cooperating with supporting institutions and organizations interested in Muslim heritage in the West and other parts of the World such as the FSTC in UK.

What are your recommendations for the near future to ensure that the contributions of Muslim scholars to the field of medicine are not left in the archives of libraries across the world but are actually utilised in a productive manner, in tandem with the developments in medicine today?

We should realize that the study of medicine of the past is meant, first and foremost, for the benefit and improvement of our medicine of today. Grasping the medical knowledge and experience of the past will, positively, help in the shaping of a better medicine for the future.

In our contemporary medical practice, there is a lot to learn from the experience of the Islamic medical scholars who developed their own original school of knowledge and practice more than 1000 years ago. The way they critically evaluated cultures and civilizations before and around them, in the light of their own experience, rejecting what is superfluous and accepting only what proves to be true, is a good example for us today to stop blind imitation and lead the way for originality, innovation and new inventions.

There is a lot for us to learn from medieval Islamic medicine in relation to its greater emphasis on the art of maintaining health and the care to prevent illness. Another lesson is that the least we use drugs the better. The illness that can be remedied by diet should not be treated by medicines, and what is relieved by a simple medicine should not be treated by a compound drug while surgical intervention should always be kept as the last resort.

It is well proven now that medicines derived from plants and natural sources are generally safer than complex chemical compounds. This has led to more interest in alternative and herbal medicine. The vast experience of the medieval Islamic scholars well recorded in hundreds of extant Arabic works on pharmacy constitute a mine field of information and provide a range of topics for modern pharmacological research bound to enrich our present day pharmacopoeias with simple and safe medicines. Indalecio Lozano, in his recent study on the therapeutic use of Cannabis sativa (L.) in Arabic medicine, came with the conclusion that Arab scientists were several centuries ahead of our current knowledge of the curative power of Cannabis sativa (L.). They knew and used its diuretic, anti-emetic, anti-epileptic, anti-inflammatory and pain-killing virtues, among others. For this reason, he even suggested that the data to be found in Arabic literature could be considered as a possible basis for future research in this field. Currently there are several ongoing pharmacological studies on medicinal plants first described Ibn al-Baytar and other scholars more than 1000 years ago. This is a very promising topic for research in which the medicine of the past is utilized for the advancement and progress of contemporary and future practice.

Islamic medicine exalted the soul, the mind and the body at one and the same time. Paying attention to spiritual as well as bodily health will help us to minimize and control the high incidence of psychosomatic disease complicating the spiritual deprivation of our contemporary materialistic way of life.

The study of the history of Islamic medicine will be also rewarded by progress and improvements in the fields of medical ethics, philosophy of medicine, psychological and mental health, care of the terminally ill patients, social medicine, nutrition, ethics of medical education and many other areas related to public health and health services.

Professor Rabieh. E. Abdel- Halim, thank you very much for participating in this interview and enlightening us with such detailed and informative responses to my questions on what is a very important topic.